GIT pdf - د. اثل - Muhadharaty

Fifth stage

Pediatric

Lec-2

.د

ثل

1/1/2016

DIARRHOEA in INFANCY & CHILDHOOD

Objectives of Lec.2

A/ correction of dehydration

To differentiate between the types of dehydration.

How you can correct different types of dehydration & how you manage the emergency?

To know the types of oral & I.V. fluid.

B/ Prevention of GE

How you can decrense the occurance of GE

C/ Complication of GE

To enumerate the complication of GE.

TYPES OF DEHYDRATION

 ISOTONIC (ISONATRAEMIC). S . Na

mmol/L

 HYPERTONIC (HYPERNATRAEMIC).

S . Na >

145

(

151

)

mmol/L

 HYPOTONIC(HYPONATRAEMIC). S . Na < (135)130 mmol/L.

CORRECTION OF DEHYDRATION

ORAL REHYDRATION THERAPY

 Mild to moderate dehydration from diarrhea of any cause can be treated

effectively using a simple, oral rehydration solution (ORS) containing glucose and
electrolytes. The ORS relies on the coupled transport of sodium and glucose in the
intestine (Facilitated transport of SODIUM by absorption of GLUCOSE )

 ORT is less expensive than IV therapy and has a lower complication rate.
 IV therapy still may be required for patients with severe dehydration; patients

with uncontrollable vomiting; patients unable to drink because of extreme
fatigue, stupor, or coma; or patients with gastric or intestinal distention.

Physiologic Basis of ORT

ORS



NaCl: 3.5 gm



NaHCO3: 2.5 gm



KCl: 1.5 gm



Glucose: 20 gm



Add 1 Liter of pure water

ORS ( WHO 2005)



[Na] 75mmol/L



[Cl] 65mmol/L



[HCO3] 10mmol/L



[K ] 20mmol/L



Glucose 13.5 g/L



Osm 245 mosm/L

Choices of ORS

ORT

REHYDRATION PHASE



For MILD Dehydration :
50 cc /Kg/ 4 Hr.



For MODERATE Dehydration:
100 cc /Kg/ 4 Hr

MAINTENANCE PHASE

MILD Diarrhea : 100 cc /Kg/24Hr
SEVERE Diarrhea : 10-15 cc /Kg/ Hr
in addition to milk feeds until diarrhea stops

INTRAVENOUS REHYDRATION

ONGOING LOSS

MAINTENANC

INTRAVENOUS

REHYDRATION

DEFICIT

DEFICIT

Calculated According to The Clinical Assessment For Severity of Dehydration

Water Deficit

Percent dehydration × weight

Resuscitation Phase



The child with dehydration requires acute intervention to ensure that there is
adequate tissue perfusion. This resuscitation phase requires rapid restoration of
the circulating intravascular volume. This restoration should be done with an
isotonic solution, such as normal saline or Ringer's lactate. Blood is an appropriate
fluid choice for a child with acute blood loss.



The child is given a fluid bolus, usually 20 mL/kg of the isotonic solution, over
about 20 minutes. A child with severe dehydration may require multiple fluid
boluses and may need to receive fluid at a faster rate.



The initial resuscitation and rehydration is complete when the child has an
adequate intravascular volume. Typically the child has some general clinical

improvement, including a lower heart rate, normalization of the blood pressure,
improved perfusion, and a more alert affect.



Potassium is not usually included in the intravenous fluids until the patient voids.

NOTE

The resuscitation phase (treatment of shock state ) is same in iso, hypo, &
hypernatremic dehydration

MAINTENANCE



Maintenance fluids are composed of a solution of water, glucose, sodium
potassium, and chloride. This solution replaces electrolyte losses from the urine
and stool and water losses from the urine, stool, skin, and lungs. The glucose in
maintenance fluids provides approximately 20% of the normal caloric needs of the

patient. This percentage is enough to prevent the development of starvation
ketoacidosis and diminishes the protein degradation that would occur if the
patient received no calories. Glucose also provides added osmoles, avoiding the
administration of hypotonic fluids, which may cause hemolysis.



Maintenance fluids do not provide adequate calories, protein, fat, minerals, or
vitamins. Because of inadequate calories, a child on maintenance IV fluids loses
0.5% to 1% of real weight each day. Patients should not remain on maintenance
therapy indefinitely; parenteral nutrition should be used for children who cannot
be fed enterally for more than a few days. Parenteral nutrition is especially
important in a patient with underlying malnutrition.

Goals of Maintenance Fluids



Prevent dehydration



Prevent electrolyte disorders



Prevent ketoacidosis



Prevent protein degradation

Body Weight Method for Calculating Daily Maintenance Fluid Volume

First 10 Kg 100 cc /Kg/24Hr

Second 10 Kg 50 cc /Kg/24Hr

> than 20 Kg 20 cc /Kg/24Hr

NOTE: The maximum total fluid per day is normally 2,400 mL.

Maintenance requirements of electrolytes:



Sodium: 2 - 3 mEq/kg/day



Potassium: 1 - 2 mEq/kg/day.

Composition of Maintenance fluids:

Child WT < 10Kg:

D5 + ¼ NS (38.5mEq/L) + 20 mEq/L of [K]

Child WT > 10Kg:

D5 + ½ NS (77mEq/L) + 20 mEq/L of [K]

NOTE: These guidelines assume that there is no disease process present that would require
an adjustment in either the volume or the electrolyte composition of maintenance fluids

ONGOING LOSSES



Calculated CC for CC and mmol for mmol and added to the rehydrating solution.



Replacement solutions should have approximately the same electrolyte
composition as the fluid that is lost. Electrolyte content can be measured directly,
or a solution can be selected based on the typical electrolyte composition of
diarrhea or gastric losses

REPLACEMENT OF LOSSES



< 10Kg BW: 60-120 mL ORS for each diarrheal stool or vomiting episode
>10 kg BW: 120-240 mL ORS for each diarrheal stool or vomiting episode



if unable to drink, administer through nasogastric tube or administer 5% dextrose
in normal saline with 20 mEq/L potassium chloride IV

Fluid Management of Dehydration



Restore intravascular volume
Normal saline: 20 mL/kg over 20 min (repeat until intravascular volume restored)
(maximum = 1 L over 2 hr)



Calculate 24-hr water needs
Calculate deficit water
Calculate maintenance water



Select an appropriate fluid (based on total water and electrolyte needs)



Administer half the calculated fluid during the first 8 hr, first subtracting any boluses
from this amount



Administer the remainder over the next 16 hr



Replace ongoing losses as they occur

TYPES OF IV FLUID

HYPONATREMIC DEHYDRATION

Hyponatremic dehydration produces more substantial intravascular volume depletion
due to the shift of water from the extracellular space into the intracellular space. In
addition, some patients have symptoms, predominantly neurologic, as a result of
hyponatremia

Treatment



Treatment of hypovolemic hyponatremia requires administration of IV fluids with
sodium to provide maintenance requirements and deficit correction and to
replace ongoing losses

solution

Glucose (g/l)

Na+

K+

Ca+2

Cl-

Lactate

D5W

D10w

100

154

½ NS

¼ NS

38.5

D5NS

154

D5 ½
NS

0.2 NS

3%NaCl

513

130

109



Most patients with hyponatremic dehydration do well with the same basic
strategy for correction of Isonatremic dehydration.



The initial goal in treating hyponatremia is correction of intravascular volume
depletion with isotonic fluid (NS or LR).



An overcorrection in the serum sodium concentration (>135mMol/L) is associated
with an increased risk of central pontine myelinolysis (CPM).



The risk of CPM also increases with overly rapid correction of the serum sodium
concentration, so it is best to avoid increasing the sodium by >12 mEq/L each 24
hr.



Emergency treatment of symptomatic hyponatremia, such as seizures, uses IV
hypertonic saline to increase the serum sodium concentration rapidly, which leads
to a decrease in brain edema.



Each 1 ml/Kg of 3% sodium chloride increases the serum sodium by approximately
1 mEq/L.



A child often improves after receiving 4 to 6 mL/kg of 3% sodium chloride.



The aim should be to increase the serum sodium concentration to not more than
130 mEq/L.

HYPERNATREMIC DEHYDRATION

Hypernatremic dehydration is the most dangerous form of dehydration due to
complications of hypernatremia and of therapy.

Hypernatremia can cause serious neurologic damage, including central nervous system
hemorrhages and thrombosis. This appears to be secondary to the movement of water
from the brain cells into the hypertonic extracellular fluid, causing brain cell shrinkage
and tearing blood vessels within the brain

Clinical Manifestations

Children with hypernatremic dehydration often appear less ill than children with a
similar degree of isotonic dehydration. Urine output may be preserved longer, and there
may be less tachycardia. Children with hypernatremic dehydration are often lethargic
and irritable when touched. the pinched abdominal skin has a "doughy" feel.

Hypernatremia may cause fever, hypertonicity, and hyperreflexia.

More severe neurologic symptoms may develop if cerebral bleeding or thrombosis
occurs.

Treatment



Too rapid treatment of hypernatremic dehydration may cause significant morbidity
and mortality.



Idiogenic osmoles are generated within the brain during the development of
hypernatremia. These idiogenic osmoles increase the osmolality within the cells of
the brain, providing protection against brain cell shrinkage secondary to movement
of water out of cells into the hypertonic ECF. They dissipate slowly during correction
of hypernatremia.



With rapid lowering of the extracellular osmolality during correction of
hypernatremia, there may be a new gradient created that causes water movement
from the extra-cellular space into the cells of the brain, producing cerebral edema.
Symptoms of the resultant cerebral edema can produce seizures, brain herniation,
and death.



To minimize the risk of cerebral edema during correction of hypernatremic
dehydration, the serum sodium concentration should not decrease more than 12
mEq/L every 24 hours. The deficits in severe hypernatremic dehydration may need to
be corrected over 2 to 4 days



the initial resuscitation-rehydration phase of therapy remains the same as for other
types of dehydration.

Typical fluids:

D5 in ¼ NS ( ½ NS) + 20 mEq/L [K]



Seizures are the most common manifestation of cerebral edema from an overly
rapid decrease of the serum sodium concentration during correction of
hypernatremic dehydration



Acutely, increasing the serum concentration via an infusion of 3% sodium chloride
can reverse the cerebral edema.

Monitoring Therapy

  Vital signs:
o  Pulse
o  Blood pressure
  Intake and output:
o  Fluid balance
o  UOP & specific gravity
  Physical examination:
o  Weight
o  Clinical signs of depletion or overload
  Electrolytes

DRUG THERAP

ANTIMICROBIALS



Campylobacter Erythromycin



Clostredia difficle Vancomycin, Metronidazol



Salmonella Amp, TMP-SMZ ,Chloram,3rd GCS



Shigella Co-TMZ,Nalidixic acid, 3rd GCS



V cholerae Tetracycline,Co-TMZ



G lambilia Metronidazole



E histolytica Metronidazole

Nitazoxanide

an anti-infective agent, has been effective in the treatment of a wide

variety of pathogens including G. lamblia, E. histolytica, C. difficile, and rotavirus.

Although preliminary data suggest that nitazoxanide may be of use in nonspecific acute
secretory diarrhea, these data need replication in further studies.

Medications that slow gut motility diphenoxylate, loperamid & anticholinergics are
COTRAINDICATED

Racecadotril,

an enkephalinse inhibitor, has inconsistently been shown to reduce stool

output in patients with diarrhea. Experience with this drug in children is limited, and for
the average child with acute diarrhea it may be unnecessary.

Antiemetic

agents such as the phenothiazines are of little value and are associated with

potentially serious side effects (lethargy, dystonia, malignant hyperpyrexia). Nonetheless,
ondansetron is an effective and less-toxic antiemetic agent. Because persistent vomiting
can limit oral rehydration therapy, a single sublingual dose of an oral dissolvable tablet of

ondansetron (4 mg 4-11 yr and 8 mg for children >11 yr [generally 0.2 mg/kg]) may be
given.

However, most children do not require specific antiemetic therapy; careful oral rehydration
therapy is usually sufficient.

Probiotic

The use of probiotic nonpathogenic bacteria for prevention and therapy of diarrhea has
been successful in developing countries. In addition to restoring beneficial intestinal flora,
probiotics can enhance host protective immunity.

A variety of organisms (Lactobacillus, Bifidobacterium) have a good safety record.

Enteral Feeding and Diet Selection

Continued enteral feeding in diarrhea aids in recovery from the episode, and a continued
age-appropriate diet after rehydration is the norm.

Once rehydration is complete, food should be reintroduced while oral rehydration can be
continued to replace ongoing losses from emesis or stools and for maintenance. Breast-
feeding or nondiluted regular formula should be resumed as soon as possible. Foods with
complex carbohydrates (rice, wheat, potatoes, bread, and cereals), lean

meats, yogurt,

fruits, and vegetables are also tolerated. Fatty foods or foods high in simple sugars (juices,
carbonated sodas) should be avoided.

COMPLICATIONS

 Renal Failure

o  Dehydration
o  Acute Tubular Necrosis
o  Haemolytic-Uraemic Synd.
o  Renal Vein Thrombosis

  Hypokalaemia  and    Paralytic   Ileus.
  Secondary    Lactose  Intoleranc
  Fluid  Overload and  Pulmonary  Edema

 Convulsions

o  Fever.
o  Hypoglysemia.
o  Hypocalcemia.
o  Hyponatremia.
o  Hypernatremia.
o  Hypomagnesemia.

o Meningitis.
o

Cerebral Vascular Thrombosis.

Prevention



Promotion of Exclusive Breast-feeding



Improved Complementary Feeding Practices



Rotavirus Immunization



Improved Water and Sanitary Facilities and Promotion of Personal and Domestic
Hygiene



Improved Case Management of Diarrhea